innovative approaches to researching governance
DESCRIPTION
This presentation was given at the 3rd RESYST annual meeting in Hanoi, Vietnam, 2013, during a workshop on Universal Health Coverage (UHC). It gives a background to RESYST research on Governance issues and how these relate to the UHC debates. The presentation was given by Professor Lucy Gilson from the Health Economics Unit at the University of Cape TownTRANSCRIPT
Innovative approaches to researching governance
issues for UHC“International Experience on Provider Payment Reforms for Universal Health
Coverage”, Hanoi 16th Sept 2013
Outline
1.Governance and UHC
1.Researching governance within RESYST
‘It is more useful to think of UHC as a direction, rather than as a destination’
Kutzin, 2013 p.604
…pursuing UHC requires coordinated policy action & implementation, across system
functions and over time
Kutzin, 2013
De Savigny & Adams, 2009
Decision-making by people is at the heart of health system governance
Governance issues for UHC
Governance
…of UHC and the health system
… and of change/reform itself
1) The hardware: establish frameworks of accountability & spread power
Governance structures• Develop a coherent network of ‘structures’
across the health system that spread power for decision-making across actors
• Develop legislative frameworks that underpin the structures and their power to act, and hold them accountable upwards and outwards
2) The software: enable the responsible exercise of power by system actors
‘Governance is about the (formal & informal) rules that distribute roles and responsibilities among societal actors and that shape the interactions among them (decision-making)’
Brinkerhoff & Bossert (2008)
Influencing decision-making?
• Through a combination of:– values & principles• Professional ethics• Transparency
– leadership & role modeling– relationships of accountability– information– financial incentives
3) The governance of change: maintain a consistent path and learn through doing
Thai experience
Always important
• Sustained political leadership & commitment to change
• Forming partnerships• Engaging and managing stakeholders• Sustained technical intensity & support
Plan - Do - Study - Act
But also:
Expect the unexpected
Encourage learning processes & cultures
Understanding governance: the Resyst approach
The tangible software:• Sets of human resources • Management knowledge &
skills • Formal management
processes
The intangible software:• The informal rules,
communication patterns, values, norms that shape relationships and interactions among actors (relative power, trust, civic-mindedness)
Leadership
Lead
ersh
ip
The hardware: e.g. a coherent network of ‘structures’ across the health system that spread power; legislative frameworks that underpin accountability; resource levels & distribution patterns signaling value
Governance as collective organisational capacity
RESYST governance focus
• The micro-practices of governance, and what influences them
the decision-making practices of public sector leaders working within the routines of the health system
• And how these practices influence accountability, policy implementation & health system change
Research challenges
• Micro-practices of governance are dynamic & complex, hard to observe
• Difficult to disentangle governance effects from other health system elements/changes
• Seek to inform and support continuing processes of decision-making, rather than to identify a single policy intervention
The job of the health system researcher
‘...is to illuminate the processes of change and experience that they observe...
to make a contribution ... to the social process of understanding or promoting change.’
Barnes et al., 2005
Critical reflection
Learning through
doing
Research to support learning
RESYST governance research
• Learning sites within the ‘District Health System’
• Continuous engagement over time within a context
• Focus on planning & priority setting
• Understanding implementing actors’ 'theories of change’ for system reforms
• Focus on specific UHC-related reforms (South Africa, Tanzania, Nigeria)
Encouraging reflection about decision-making practices through research
Why focus on peripheral facilities?
RESYST learning sites
Supporting distributed leadership for UHC
‘Probably the most complex challenge in health systems is to nurture persons who can develop
the strategic vision, technical knowledge, political skills, and ethical orientation to lead the complex processes of policy formulation and implementation. Without leaders, even the best designed systems will fail’ (Frenk
2010: 2)